DIFFERENTIAL DIAGNOSIS OF FEVER

Differential Diagnosis of Fever

Barbara Rath, M.D. University Childrens Hospital Basel (UKBB)
Barbara Rath 2007

Where and how should we measure body temperature? What constitutes normal temperature? What constitutes fever? What causes fever? What is Fever of Unknown Origin (FUO)?

Barbara Rath 2007

WHERE AND HOW SHOULD WE MEASURE BODY TEMPERATURE?

Barbara Rath 2007

Thermoscope (Galileo Galilei, 1592): First instrument to measure temperature

Barbara Rath 2007

Thermometer (Santorio Sanctorius, 1592)

Barbara Rath 2007

Barbara Rath 2007

Curved thermometers for sublingual insertion (BMJ 1912;1:1137)

Barbara Rath 2007

Benjamin Rush (1745-1813): A Moral Barbara Rath 2007 Thermometer (1812)

VARIATIONS IN SUBLINGUAL TEMPERATURE BY LOCATION

THE INFRARED AURAL THERMOMETER

TM thermometersalthough convenienttend to give highly variable readings that correlate poorly with simultaneously obtained oral or rectal readings. Mackowiak P A in: Mandel G L, Bennett J E, Dolin R (Eds) Principles and th
Practice of Infectious Diseases, 6 Ed, 2005, pg 704

Once outstanding issues are addressed, the tympanic site is likely to become the gold standard for measuring temperature in children. El-Radhi
A S, Barry W: Arch Dis Child 2006; 91: 351-356.

Clin Epidemiol 2006; 59: 354-57

infrared ear thermometry would fail to diagnose fever in three or four out of every ten febrile children (with fever38C or above). Dodd S R, et al: ITT measurements more accurately reflect core temperatures than any other measurement site during febrile and nonfebrile periods in children.
Nimah M M, et al: Pediatr Crit Care Med 2006; 7: 48-55.

Our findings suggests that infrared ear thermometry does not show sufficient agreement with an established method of temperature measurement to be used in situations where body temperature needs to be measured with precision. Craig J V, et al: Lancet 2002; 360: 603-609.
Barbara Rath 2007

Difference max vs min = 0.9C or 1.8F Barbara Rath 2007

DIFFERENTIAL DIAGNOSIS OF FEVER

WHAT IS NORMAL BODY TEMPERATURE?

Where and how should we measure body temperature? What constitutes normal temperature temperature? What constitutes fever? What causes fever? What is Fever of Unknown Origin (FUO)?
Barbara Rath 2007

35.7C (96.2F) 36.0C (96.8F) 36.5C (97.7F) 37.0C (98.6F) 37.5C (99.5F) 37.7C (99.9F)

Barbara Rath 2007

NORMAL CORE TEMPERATURE

Best site(s) to determine true normal core temperature is:

NORMAL BODY TEMPERATURE?

Carl Rheinhold August Wunderlich: Das Verhalten der Eigenwrme in Krankenheiten (Leipzig,1868)

Hypothalamic artery Pulmonary artery Rectum (5 cm) Sublingual artery (oral) Tympanic membrane Temporal artery Axillary artery Skin (umbilicus)
Barbara Rath 2007

Analyzed ~million observations on ~25,000 adults 22 cm long, mercury-in-glass thermometer Used axillary site, twice daily, x15-20 minutes Temperature oscillates even in health persons according to time of day by 0.5C = 0.9F Women have slightly higher normal temperatures than men and often show greater and more sudden changes of temperature

Barbara Rath 2007

NORMAL BODY TEMPERATURE?

When

NORMAL ADULT ORAL TEMPERATURES

37.0C 98.6F

the organism (man) is in a normal condition, the general temperature of the body maintains itself at the physiologic point: 37C = 98.6F

PROBLEM: Tests with one of Wunderlichs thermometers suggest that his instruments may have been calibrated higher than todays instruments by as much as 1.4 to 2.2C. * Mean, Median: 98.2F
Mackowiak P A et al: JAMA 1992; 268: 1578-80 Barbara Rath 2007

* Mackowiak P A, Worden G: Clin Inf Dis 1994; 18: 458-67.

Barbara Rath 2007

NORMAL RECTAL TEMPERATURE HEALTHY INFANTS & CHILDREN

AGE
< 3 MOS 3 MOS 6 MOS 1 YEAR 3 YEARS 5 YEARS 7 YEARS 9 YEARS 11 YEARS 13 YEARS

Normal body temperature is a range of values, affected by:

TEMPERATURE F & C (SD)

99.5 (0.8) 99.4 (0.8) 99.5 (0.6) 99.7 (0.5) 99.0 (0.5) 98.6 (0.5) 98.3 (0.5) 98.1 (0.5) 98.0 (0.5) 97.8 (0.5)
Barbara Rath 2007

Age: Infant > child > adolescent, adult Sex: females > males (mean: 0.2C, 0.3F) Race: Black > Caucasian (mean: 0.1C, 0.1F) Time of day: afternoon > early morning Level of Activity: post-exercise > resting Meals: hot > cold; chewing, smoking Ambient temperature Placement within site of measurement Duration of measurement (Hg thermometers) Nature & calibration of device used

37.5 (0.4) 37.4 (0.4) 37.5 (0.3) 37.6 (0.2) 37.2 (0.2) 37.0 (0.2) 36.8 (0.2) 36.7 (0.2) 36.7 (0.2) 36.5 (0.2)

Watson E H: Growth and Development of Children (1978); Herzog L W, Coyne L J: Clin Pediatr 1993; 32:

Barbara Rath 2007

NORMAL TEMPERATURES vs SITE

SITE MEAN C F 36.4 97.5 36.6 97.9 37.0 98.6 RANGE C 34.7 37.3 35.5 37.5 36.6 37.9

AXILLARY SUBLINQUAL RECTAL

TYPICAL DAILY TEMPERATURE FLUCTUATION (PO, ADOLESCENT) El-Radhi A S, Barry W: Arch Dis Child 2006; 91: 351-356
Richardson G S, et al: Sleep 1982; 5 (Supp 2):S82 Barbara Rath 2007
Barbara Rath 2007

DIFFERENTIAL DIAGNOSIS OF FEVER

Where and how should we measure body temperature? What constitutes normal temperature? What constitutes fever? What causes fever? What is Fever of Unknown Origin (FUO)?

Sund-Levander M, Forsberg C, Wahren LK. Normal oral, rectal, tympanic and axillary body temperature in adult men and women: a systematic literature review. Scand J Caring Sci 2002;16(2):122-8.
Barbara Rath 2007 Barbara Rath 2007

HISTORY OF FEVER
Sumerian (2500 BC): inflammation or hot thing meaning fever

HISTORY OF FEVER
Sumerian (2500 BC): inflammation or hot thing meaning fever

Egyptian (1700 BC): fever

Egyptian (1700 BC): fever

Chinese (2nd Century): hot disease

Barbara Rath 2007

Chinese (2nd Century): hot disease

Barbara Rath 2007

WHAT IS FEVER? PHYSIOLOGIC DEFINITION

WHAT IS FEVER? CLINICAL DEFINITION

A state of elevated core temperature which is often, but not necessarily, part of the defensive responses of multicellular organisms (host) to the invasion of live (microorganisms) or inanimate matter recognized as pathogenic or alien
- IUPS Commission for Thermal Physiology (2001)

A pyrogen-mediated rise in body temperature above the normal range

Barbara Rath 2007

Barbara Rath 2007

WHAT IS NOT FEVER? HYPERTHERMIA

WHAT TEMPERATURE = FEVER?

A failure of thermoregulatory homeostasis due to uncontrolled heat production1, inadequate heat dissipation2, or defective thermoregulation3 leading to an unregulated rise in body temperature in which pyrogenic cytokines are not directly involved and against which standard antipyretics are generally ineffective.
1. Malignant hyperthermia, exercise, endocrine, drug (e.g. thyroxine) 2. Neonates, bundling, heat stroke, drug (e.g. atropine) 3. Neonates, CNS damage
Barbara Rath 2007

37C (98.6F) 37.7C (100F) 38C (100.4F) 38.3C (101F) 39.1C (102.4F)

Barbara Rath 2007

WHAT TEMPERATURE = FEVER? PEDIATRIC LITERATURE What do Pediatric and ER Residents Think ?

Rudolphs Pediatrics
The

temperature most commonly used to define fever threshold in children is 38C (100.4F), rectal, although lower oral temperatures in adolescents and adults (37.2 - 37.8C) may indicate a febrile response.

Textbook of Pediatric Emergency Medicine

For

Survey: 132 Pediatric Programs, 38 Emergency Medicine Programs Baraff L J: Management of the febrile child: A survey of pediatric and emergency medicine residency directors. Pediatr Inf Dis J 1991; 10: 795 Barbara Rath 2007

the appropriately dressed child who has been at rest 30 minutes, rectal temperature of 38C (100.4F) is fever
Barbara Rath 2007

WHAT TEMPERATURE = FEVER? & MORE PEDIATRIC LITERATURE.

WHAT TEMPERATURE = FEVER? THE PEDIATRIC ID LITERATURE

Pediatrics (Osborn, DeWitt, First) The most commonly accepted minimum temperature defining fever is 38C (100.4F). Current Pediatric Therapy
fever

Principles and Practice of Pediatric Infectious Diseases In general, values higher than 37.8C (100F) are considered to be fever Textbook of Pediatric Infectious Disease Generally, the accepted range of rectal temperature is 36.1C to 37.8C (97F to 100F)..Clearly, a body temperature slightly above an arbitrary upper limit of 37.8C (100F) does not always imply a pathologic process. Pediatric Infectious Diseases. Principles and Practice No definition given
Barbara Rath 2007

is defined as rectal temperature above 38C (100.4F).

Nelsons Pediatrics No definition given

Barbara Rath 2007

WHAT TEMPERATURE = FEVER? THE JOURNALS.

Fever as an Adverse Event Following Immunization (AEFI)

Contemporary Pediatrics (1997)

Rectal temperature >38 C (100.4 F) Tympanic temperature >38 C (100.4 F) Oral temperature >37.8 C (100 F) Axillary temperature >37.2 C (99 F)

Berlin C W Jr: Fever in children. A practical approach to management

Barbara Rath 2007 Barbara Rath 2007

Fever as an AEFI The Brighton Collaboration Case Definition

Fever is defined as the endogenous elevation of at least one measured body temperature of >= 38 C.

FEVER vs NORMAL ADULT ORAL TEMPS

37.0C 98.6F

*
38 C 100.4 F

The value of >38C is accepted as reflecting an abnormal elevation of temperature, irrespective of device, anatomic site, age, or environmental conditions. While it is recognized that this value is to some extent arbitrary, it is based upon a conservative interpretation of definitions proposed and used by clinicians, investigators, and the public at large.

S. Michael Marcy et al., Vaccine 2004; 22: 551-556

Barbara Rath 2007

* Mean, Median: 98.2F

Mackowiak P A et al: JAMA 1992; 268: 1578-80 Barbara Rath 2007

INDIVIDUAL VARIATIONS AND THE DEFINITION OF FEVER

DIFFERENTIAL DIAGNOSIS OF FEVER

Statement: She always runs a low temperature and 37.5 is a fever for her Response: You will never convince the caregiver to the contrary, so work with it: There are no data to confirm or refute this observation.

Where and how should we measure body temperature? What constitutes normal temperature? What constitutes fever? What causes fever? What is Fever of Unknown Origin (FUO)?
Barbara Rath 2007

Barbara Rath 2007

WHAT CAUSES FEVER?

Sumerian (3000 BC)

Evil spirits (Nergal & Ashakka) Demonic possession Imbalance of good and evil Fire demons Takman & Yakshma Disturbances of the humours: bile, air, phlegm Excess of phlegm vs blood, yellow bile, black bile Excess of yellow bile vs phlegm, blood, black bile Demonic possession Fermentation and putrefaction in the blood and gut Friction from blood rushing through the vessels; inflammation..
Barbara Rath 2007 Barbara Rath 2007

Egyptian (1700 BC)

Chinese (1000 BC)

Indian (800 BC 1000 AD)

Greek and Roman (400 BC 200 AD)

Medieval (500 1350 AD)

Renaissance (1300 1600 AD)

18th Century

Non-Infectious Causes
Hyperthyroidism Hodgkin Disease Pulmonary Infarction Hypernephroma Reginoal Ileitis Aplastic Anemia Leukemia Fracture Rheumatic Fever Rheumatic Arthritis
Barbara Rath 2007

Infectious causes
Cerebral Abscess
Cerebral Hemorrhage Drug Fever Dermatomyositis Bronchogenic CA Myocardial Infarction Pheochromocytoma Periatrieritis Nodosa Thrombophlebitis

Meningitis Infectious Mononucleosis Tracheobronchitis Pneumonia Subphrenic Abscess Infectious Exanthema Appendicitis Osteomyelitis Septic Arthritis

Sinusitis Dental Abscess Tuberculosis Subacute Bacterial Endocarditis Empyema Pyelonephritis Diverticulitis Prostatic Abscess Cellulitis

Barbara Rath 2007

ANATOMY OF THERMOREGULATION

PATHOGENESIS OF FEVER

Mackowiak P A: Arch Int Med 1998; 158:1870-1881 Barbara Rath 2007

Mackowiak P A:Barbara Arch Int Med 1998; 158:1870-1881 Rath 2007

PATHOGENESIS OF FEVER

TRUE NORMAL CORE TEMPERATURE

Best site(s) to determine true normal core temperature is:

Hypothalamic artery Pulmonary artery Rectum (5 cm) Sublingual artery (oral) Tympanic membrane Temporal artery Axillary artery Skin (umbilicus)
Barbara Rath 2007

Acetaminophen, Ibuprofen

Mackowiak P A:Barbara Arch Int Med 1998; 158:1870-1881 Rath 2007

DIFFERENTIAL DIAGNOSIS OF FEVER

FUO IN CHILDREN
Fever of unknown origin is characterized by daily fever persisting for more than 3 weeks.

Where and how should we measure body temperature? What constitutes normal temperature? What constitutes fever? What causes fever? What is Fever of Unknown Origin (FUO)?

infectious, rheumatologic disorders, and malignancy.

Chronic episodic fever of unknown origin is characterized by fever lasting for a few days to a few weeks, followed by a fever-free interval and a sense of well-being.

Mediterranean fever, the hyper-immunoglobulin D syndrome, familial Hibernian fever, Behcet disease, the syndrome of periodic fever, aphthous stomatitis, pharyngitis and adenitis, and cyclic neutropenia.
Barbara Rath 2007

Barbara Rath 2007

FUO IN CHILDREN

FUO IN CHILDREN

Majeed HA. Curr Opin Rheumatol. 2000 Sep;12(5):439-44.

Barbara Rath 2007 Barbara Rath 2007

Barbara Rath 2007

Barbara Rath 2007

ALSO RULE OUT:

Know where to look!!!

Hay Fever Cabin Fever Island Fever World Cup Fever Saturday Night Fever

Barbara Rath 2007

Barbara Rath 2007

Clinical Vignettes..

Barbara Rath 2007

Barbara Rath 2007

CASE #1: NEONATE WITH FEVER

YOUR NEXT STEP IS.?

A 3 week old boy comes to your office because he slept through his noon feeding time, seems sleepier than usual to the parents, and had a rectal temperature of 38.1C (100.6F). Examination is entirely normal, including vital signs and temperature. He has a brisk, strong cry and good muscle tonus, but the cry is not sustained and he sucks only briefly on his bottle and then becomes quiet. What else would you like to know or do?

Admit, start antimicrobial Rx (cefotaxime + ampicillin or ceftriaxone + ampicillin or gentamicin + ampicillin) Admit, get lab studies, and start antimicrobial Rx Admit, observe without lab studies or antimicrobials Get lab studies and await results to decide if pt needs admission or can be followed from home

Barbara Rath 2007

Barbara Rath 2007

LAB STUDIES YOU COULD ORDER ARE?

CBC and differential UA/UC Blood culture CSF analysis and culture Chest P-A & lateral radiograph Sedimentation rate (ESR) C-reactive protein (CRP) Procalcitonin IL-6 or IL-8 CD11b, CD64 Granulocyte colony stimulating factor
Mishra U K, et al: Arch Dis Child Fetal Neonatal Ed 2006; 91: F208-F212
Barbara Rath 2007

CASE #1: NEONATE WITH FEVER (CONTD)

Lab results:

CBC: 7,600 WBC with 44N, 47L, 7M, 2E; Hgb 11/33 Cath UA: yellow, cloudy. Sp gr 1.010, pH 7.0. Sugar, protein, ketones, bili all neg. Hgb 1+, LE 1+, nitrite neg. Micro: WBC 10-25/HPF, bacteria few. CSF: clear, 1 RBC, 4 WBC (2 PMNs), sugar 52, protein 69, Gram stain neg. Chest film: normal Two days later lab reports >100,000 E coli in the urine

Barbara Rath 2007

10

THE VALUE OF THE LABORATORY IN EVALUATION OF NEONATAL INFECTION

THE VALUE OF THE LABORATORY IN EVALUATION OF NEONATAL INFECTION

Tests and Panels for Early Onset Neonatal Sepsis PPV: 5% - 69% (Mean: 36%) NPV: 93% - 100% (Mean: 97.5%) Tests and Panels for Late Onset Neonatal Sepsis PPV: 71% - 93% (Mean 79%) NPV: 75% - 97% (Mean 86%)

the usefulness of a test will depend above all, on the clinical condition of the baby. If the baby is really very sick, the test will not give very much additional informationif the baby is evidently wella positive test result (will) not dramatically increase the probability that the baby is infected BUT, what about the baby that isnt really very sick and isnt evidently well..?
Chiemsa C, et al: : Clin Chem 2004; 50: 279-187
Barbara Rath 2007

Weinberg G A, DAngio C T in Remington J S, Klein J O: Infectious Diseases of the Fetus and Newborn Infant, 6th Ed, 2006, Pg 1216.
Barbara Rath 2007

ROCHESTER LOW-RISK CRITERIA FOR SERIOUS BACTERIAL ILLNESS (0-3 MO)

Hx: Term (>37 Weeks) No antimicrobials Never hospitalized No unexplained hyperbilirubinemia No chronic or underlying illness Not hospitalized longer than mother PE: Appears generally well No evidence skin, bone, soft tissue, joint, or ear infection Lab: WBC 5000-15,000 Absolute band <1500 Spun urine <10 WBC/HPF Stool <5 WBC/HPF (if diarrhea) Barbara Rath 2007

TAIWAN LOW-RISK CRITERIA FOR SERIOUS BACTERIAL ILLNESS (0-28 DAYS)

PE: Appears well No evidence ear, eye, soft tissue infection LAB: WBC 5,000 15,000 Absolute band <1500 Spun urine <10 WBC/HPF CRP <20 mg/L [ESR <30 mm/hr]

Chiu C-H et al: Pediatr Infect Dis J 1994;13:946-949 & 1997;16: 59-63 Barbara Rath 2007

YOUNG INFANT OBSERVATION SCALE (0-2 MO)

MANAGEMENT OF THE FEBRILE INFANT

Decisions on management of febrile (or afebrile) infants should be based mostly on an overall clinical impression, not a single clinical measurement such as temperature nor a single lab value such as the WBC count Clinical observation has been objectified to some extent in the Young Infant Observation Scale and the Yale Observation Scale
Barbara Rath 2007

AFFECT Smiles or not irritable (1)* Irritable, consolable (3) Irritable, not consolable (5) RESPIRATORY STATUS & EFFORT No impairment, vigorous (1) Mild-moderate compromise (tachypnea, retractions, grunting) (3) Respiratory distress or inadequate effort (apnea, respiratory failure (5) PERIPHERAL PERFUSION Pink, warm extremities (1) Mottled, cool extremities (3) Pale, shock (5)
* No infant who smiled had an SBI Bonadio W A, et al: Pediatr Inf Dis 1993; 12: 111-114 Barbara RathJ 2007

11

EFFICACY OF LOW-RISK CRITERIA FOR EXCLUDING SERIOUS NEONATAL BACTERIAL INFECTIONS

Ooooooops

Taiwan Criteria PPV: 33.6% NPV: 99.2% (bacteremia/meningitis: 100%) Afula Criteria PPV: 32% NPV: 99.4% Rochester Criteria PPV: 27%*, 35%, 12% NPV: 94%*, 97%, 99% Young Infant Observation Scale (7) PPV: 37% NPV: 96%
* Ferrera P C, et al: Am J Emerg Med 1997; 15: 299-302 Gara G, et al: Acad Emerg Med 2005; 12: 921-925. Barbara Rath 2007 Jaskiewicz J A, et al: Pediatrics 1994; 94: 390-396

11-month old male infant with 12 hr Hx low grade fever, irritability, intermittent crying. PE: alert, playful, smiling. Red pharynx, left TM red and bulging, flat fontanelle. 5 hrs later: T 39.9C, increasingly lethargic, bulging fontanelle. CSF cloudy, 8,200 WBC, sugar 45 mg%, protein 160 mg%, Gram-positive diplococci seen. Culture grew S pneumoniae penicillin-R

Baptist E C: Meningitis in the child with a smile. Arch Pediatr Barbara Rath 2007 Adolesc Med 1995; 149:1179

CASE #2: FEVER IN AN 18-MONTH OLD

CASE #2: FEVER IN 18-MONTH OLD (CONTD)

An 18-month old girl is brought to your office on a Thursday morning with a fever for 4 days up to 103.8F by TM thermometer. Her parents tell you she first felt warm when being put to bed on Monday and since then has been more whiny, tires somewhat more easily than usual, appetite is off a bit, but she is otherwise active, alert, and generally unfazed. ROS: Otherwise normal PMH: Non-contributory. Immunizations up to date. Family Hx: All well Social Hx: No travel, friends are well.

The enhanced urinalysis (hemocytometer count of unspun urine + Gram stain) was normal (no organisms and <10 cells/mm3). WBC: 6,400 with 74%L, 21%P, 5%M, 0E. Chest film was normal. The next day she still has a fever, but that afternoon the mother calls back concerned because a rash broke out. You tell her to bring the child in to see you. On PE you note a faint pink macular rash most prominent on the neck and trunk, slight on the face and extremities. The child is now afebrile. The mother has OCD and kept a q 4 hr record of her daughters temperatures
Barbara Rath 2007

Barbara Rath 2007

Barbara Rath 2007

Barbara Rath 2007

12

CASE #2: FEVER IN 3-36 MONTH OLD (CONTD)

The most likely diagnosis is infection due to:

HHV HHV

6 7 16(Boston exanthem), 9, 11, 25, 27, 30 A6, A9, B1, B2, B4, B5 1, 2, 3, 14 1

Echovirus

Coxsackievirus Adenovirus

Parainfluenza Rotavirus Parvovirus

B19
Barbara Rath 2007

Cherry J D in Feigin, Cherry, Demmler, Kaplan Eds): Textbook of Pediatric Infectious Diseases, 5th Edition, Pg 772. Barbara Rath 2007

Barbara Rath 2007

Barbara Rath 2007

Barbara Rath 2007

Barbara Rath 2007

13

DOES TEMPERATURE MATTER? SIGNIFICANCE OF FEVER 41.1C

Of no predictive value

Clinical assessment reliably identified those children with hyperpyrexia and serious complicationsand should be used to guide management decisions
Bonadio W A, et al: Pediatr Inf Dis J 1989; 8: 120-122

Highly febrile young children need to be evaluated as thoroughly and carefully as any other febrile child but do not merit special consideration.
Alpert G, et al: Pediatr Inf Dis J 1990; 9: 1611-63

Krugman S, Katz SL, Gershon AA, Wilfert CM. Infectious diseases of children. 9th ed. St. Louis, Missouri: Mosby Year Book Inc. 1992.
Barbara Rath 2007

We advise treatment with antibiotics for all children with hyperpyrexia who do not have a confirmed viral illness and for all children with hyperpyrexia and a confirmed viral illness who are ill enough to require hospitalization
Trautner B W, et al: Pediatrics 2006; 118: 34-40
Barbara Rath 2007

DOES AGE MATTER? INCIDENCE OF SEVERE SEPSIS BY AGE

DOES AGE MATTER? MORTALITY DUE TO SEPSIS BY AGE

Angus DC, Linde-Zwirble WT, Lidicker J, Clermonte G, Carcillo J, Pinsky MR. Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Crit Care Med 2001; 29:1303 10. Barbara Rath 2007

Girard TD, Opal SM, Ely EW. Insights into severe sepsis in older patients: from epidemiology to evidence-based management. Clin Infect Dis 2005;40(5):719-27. Barbara Rath 2007

DOES A HIGH WBC COUNT MATTER?

Children 2-24 mo old (mean: 10 mo), 1992-1994, T38.5C Leukocytosis (LK): 15,000 24,999 (n = 94) Extreme leukocytosis (EL): 25,000 (n = 69) Diagnoses
Diagnosis LK EL Otitis Media Viral Syndrome Pneumonia UTI Gastroenteritis Aseptic meningitis Adenitis Bacteremia Other*

CASE #3: 16 YEAR OLD BOY WITH FEVER

41% 18% 13% 12% 7% 2% 2% 1% 4.6%

37% 9% 15% 13% 5% 6% 6% 2% 7%

Proven SBI LK vs EL: 17% vs 25% Proven + Probable SBI: 35% vs 52% Hospitalized: 31% vs 49% 25,000-29,999: RR SBI: 1.36 30,000: RR SBI: 1.73

A 16-year old boy comes to your office with his father who is concerned because the boy had a fever for several days, but today woke up with a fever to 40C, flushed face, chills, vomited once, and even seemed a bit delirious about an hour before. He has been quite well otherwise except for an aching knee since he tripped and fell about a week ago. ROS: Otherwise non-contributory PMH: Non-contributory

All immunizations, including meningococcal vaccine.

Family Hx: All well, non-contributory Social Hx: no travel, non-contributory. Friends are well
Barbara Rath 2007

Barbara Rath 2007 *Periorbital cellulitis (3), meningitis, cellulitis, mastoiditis, osteo, septic arthritis (1 each)

14

CASE #3: 16 YEAR OLD BOY WITH FEVER (CONTD)

PE: On examination you confirm the high fever, pulse of 132; BP 97/65; sick-looking young man. Sa02: 89%. Right knee is mildly swollen and faintly pink. Otherwise, PE normal without any rash, petechiae, or mucous membrane involvement.

Barbara Rath 2007

Barbara Rath 2007

CASE #3: 16 YEAR OLD BOY WITH FEVER (CONTD)

Labs & X-ray

WBC: 9700, 43% N, 28% B, 20% L, 9% M, toxic granulations noted; Hgb 15.3, Pl 120,000 UA: 8-10 RBC / HPF ESR: 85 mm/hr, CRP: 47 D dimers (+), fibrin split products (+) ALT: 52, AST: 38 Serum albumin: 2.43 g/dL Na: 125 Creatinine 2.0; BUN 20 Chest radiograph: bilateral nodular densities

Barbara Rath 2007

Barbara Rath 2007

SOME POSSIBLE ETIOLOGIES

NEISSERIA MENINGITIDIS GROUP A STREPTOCOCCUS STAPHYLOCOCCUS AUREUS SALMONELLA TYPHOSA RICKETTSIA RICKETTSII ERHLICHIA CHAFEENSIS LEPTOSPIRA SPP
Barbara Rath 2007

Barbara Rath 2007

15

CASE #3: 16 YEAR OLD BOY WITH FEVER

SCENARIO #4: Hes had a fever, but hes been teething...

Pt started on ceftriaxone, vancomycin, gentamicin Blood culture grew out S aureus, methicillin-R Severe staphylococcal sepsis in adolescents* 90% with bone and/or joint infection 90% with pulmonary septic emboli, pneumatocoeles, and/or parapneumonic effusions 30% bacterial venous thrombophlebitis 50% Renal failure DIC Skin lesions: urticaria, e multiforme, papular-pustular
* Gonzalez B E, et al: Pediatrics 2005; 115: 642-648
Barbara Rath 2007

Signs and symptoms significantly associated 4 days before to 3 days after teething are:
Biting Drooling Rash on face Sucking Gum-rubbing Irritability Wakefulness Appetite (solids) Ear-rubbing Temp Elevation*

*Day of emergence vs before: 17% vs 12% >100F; 6% vs 3% >101F

Macknin M L, et al: Pediatrics 2000; 105:747-752
Barbara Rath 2007

Teething and Fever (Contd)

Scenario #5: His temperature was around 39 - Fever Detection by Palpation

~60% of parents use palpation as the usual method of fever assessment 85% - 99% believe they can detect fever by palpation Actual accuracy of parental palpation for fever:

Mean daily temp before 1st tooth eruption

Sensitivity: 77%1, 84%2, 90%3 , 74%4 Specificity: 82%, 76%, 78%, 86% Positive predictive value: 59%, 72%, 69%, 71% Negative predictive value: 85%, 91%, 91%, 94%

Jaber L, et al: Arch Dis Childh1992; 67:233

Barbara Rath 2007

Temp >37.5C by day before tooth eruption, 46 infants, 15 with temp 38C

1. Katz-Sidlow R, et al: Ped Acad Soc Meeting; May 2, 2006; 2. Graneto J W, Soglin D F: Ped Emerg Care 1996; 12: 183-184; 3. Ernst T N, Philp M: Amer J Dis Child 1985; 139: 546; 4.Banco L, Veltri D: Amer J Dis Child 1984; 138; 976-978. Barbara Rath 2007

Scenario #5: His temperature was around 39..*

ANXIOUS PARENTS
170 parents of young febrile children who presented to a pediatric emergency department (ED) with fever; 90-item questionnaire (State Trait Anxiety Inventory) Parents were asked what they had previously thought about and how they felt about the ED process. Mean parental anxiety was 50.1 (95% CI 48.1, 52.2), significantly elevated from adult standards (p < 0.0001). A multivariate model comprising: (1) feeling "not at all" well rested, (2) having no other children, (3) having thought about a blood test, and (4) feeling worried about trusting the physician was associated with elevated anxiety. In conclusion, parents of febrile young children in the ED are very anxious.

If it is important to know the real temperature (and it may not be) ask:
Where What How

did you take the temp?

kind of thermometer did you use? Was it below 39 or above?

long did you leave it in place?

Around?

* Translation: Im worried and I want you to worry too.

Barbara Rath 2007

Parkinson GW, Gordon KE, Camfield CS, Fitzpatrick EA. Anxiety in Parents of Young Febrile Children in a Pediatric Emergency Department: Why is it Elevated? Clinical Pediatrics 1999;38(4):219. Barbara Rath 2007

16

SUMMARY

SUMMARY
Overall clinical impression, supported by laboratory or imaging studies, rather than height of temperature or abnormal lab values alone, should be the major determinant for deciding whether or not a child has a serious bacterial illness.

Normal body temperature varies widely Fever can be arbitrarily defined as a temp of 38C (100.4F) at any site using any approved instrument Teething may be associated with minimal elevation in temperature Palpation is not an accurate way to determine presence of fever, but its not bad for its absence

Barbara Rath 2007

Barbara Rath 2007

Acknowledgements
S MICHAEL MARCY, MD CLINICAL PROFESSOR OF PEDIATRICS UNIVERSITY OF CALIFORNIA LOS ANGELES UNIVERSITY OF SOUTHERN CALIFORNIA SCHOOLS OF MEDICINE Team Lead, Brighton Collaboration Fever Working Group, Member, Brighton Collaboration Steering Committee

Barbara Rath 2007

17